As my readers know, I go to great lengths to avoid other neurologists. I do this because this branch of medicine is just chock full of personality disorders.

Don't believe me? Allow me to introduce exhibit A, which was published in the January/February 2011 issue of Practical Neurology.

click to enlarge

Because, let's face it: It takes a really special kind of whackjob to write a letter complaining about using both the words "preventive" AND "preventative" in the same article. They even get bonus points for being able to cite an article from freakin' 1964 on such an important point.

Friday, June 24, 2011

With the passing of Peter Falk today, I've seen a lot of mentions of his work. Primarily his famous role as Detective Columbo, but also for his movie roles such as "The Princess Bride" and "The In-Laws".

Nowhere in there is anyone mentioning what I thought was a screamingly funny 1990 movie he starred in called "Tune in Tomorrow". It also featured Keanu Reeves.

Several of my patients are nurses at the hospital I work at. So yesterday afternoon, while I was on rounds, one came over and asked if she could talk to me in private.

So a few minutes later I met her in an empty room. She told me that she found out last week that she's pregnant, and so she stopped her migraine medication. I told her that's fine, and congratulated her.

15 minutes later, while walking out to my car, I noticed her standing outside.

"Doctor, Wirfliss Pharmaceuticals has done a lot of total research on this drug, and we've found that the totality of our results, in total, shows a total number of benefits that improves a patient's total health."

The monthly Costco Connection magazine was left in my lobby recently, and on a quiet day I glanced through it. It featured an article asking whether or not patients should seek medical information online.

Comically, they decided to get pro and con opinions from 2 individuals- NEITHER OF WHOM IS A MEDICAL DOCTOR!

Really. The 2 experts they quoted were Dave deBronkert, who's a "voluntary co-chair for the Society for Participatory Medicine" and Judy Segal, who's an English professor at the University of British Columbia.

Now, I have nothing against either of them. I mean, they are both obviously intelligent, highly educated individuals. But I think it's pretty damn funny that the writer didn't feel it was worthwhile to, say, ask a medical doctor.*

So, Costco mag, here's my 2 cents worth.

First of all, this question is moot. Like atomic energy, cloning, and stem cells, this genie ain't going back in the bottle. People already DO look stuff up online, and unless the internet completely crashes, will continue to do so.

Second: I suppose most of you are expecting me to be adamantly against my patients looking up stuff. But ya know what? I'm not.

Most patients actually DO benefit from learning more about their diseases online. At least half of what I tell them in the office won't get absorbed anyhow. And I don't have the space to keep a million little "Living with Schnorkfloodle's Syndrome" pamphlets lying around. So I refer them to what I consider to be reputable websites (not BigPhilsguidetoParkinsonsDiseaseandroofingmaterials.com).

But there are also the cyberchondriacs. They type a few symptoms into Google, and voila! They are now convinced they have whatever got the most hits (for neurology purposes, I'd estimate that 90% of search engines lead to a self-diagnosis of MS).

It's this group that drives me nuts. They want me to prescribe treatments that are only available somewhere far away (like Senegal). Or they bring in a HUGE stack of information written by a Holostic Reflexologist on a site that has absolutely no valuable medical info at all (but because it has nice graphics it MUST be true). Or they want me to magically enroll them in some study being done in another state that I have absolutely no connection to.

This is where the real problem starts. People who don't have medical knowledge make the scary leap from symptoms, sometime quite vague, to fixating on whatever the internet says they MUST have. Medicine is a process of collecting data from several angles and working out probabilities. If you don't have the training to do that, the information in front of you can be terrifying. Not only that, most people don't understand the difference between various phases of drug trials, so a treatment that's in development suddenly becomes one they think is available.

And here's what really grates me: if these people need a car fixed, they'll do a shitload of research to find a reputable place. They wouldn't dare just grab some random stranger and ask them to repair it. But when they have a health issue they'll take the word of a pet mausoleum architect with a nice internet site over that of a reputable, trained, medical professional.

So here's the take of an uninformed yak herder pretending to be a neurologist: Is it okay for patients to learn about their health issues on the internet? Of course!

As in everything else, though, it depends on the source of the info, the person reading it, and what they do with it.

Let the buyer beware...

*I'm sure I'll hear from those of you who believe this is because we docs are secretly conspiring against you as part of some giant medico-pharma fiendish plot, and therefore can't be trusted.

Saturday, June 18, 2011

It's not uncommon for realistic families to allow stricken loved ones to die. Sometimes it involves taking them off machines, at others it just means stopping medications.

Years ago I had an older gentleman who'd had a massive stroke, and the family didn't want to have anything done. As always, the question of "how long will he go on?" came up, which is very hard to predict.

Because of the size of the stroke, and him developing brainstem herniation, I guessed about 24-48 hours.

Literally, before I'd finished THAT VERY sentence, he collapsed over to his right and the monitor went flat.

Mrs. Wreck: "Hi, I need to make an appointment with Dr. Grumpy. Some moron rear-ended me in a car wreck, and I've been having headaches, and my lawyer told me that I need to be evaluated by a neurologist for my case."

Mary: "I'm sorry, but Dr. Grumpy doesn't take medical-legal cases."

Mrs. Wreck: "But there isn't a case here?"

Mary: "You just mentioned a car accident, and that a lawyer had referred you."

Tuesday, June 14, 2011

Because, ya know, the world REALLY needed a pizza that's perfect for when it's late at night and you and your buddies are wasted from drinking too much microbrew and you need something to line your stomachs while you watch subtitled art-house flicks on DVD.

Sunday, June 12, 2011

Thank you for coming in on this lovely Friday afternoon, ma'am. I guess you called around 1:30 today, and since we didn't have a 4:00, which is my last slot of the day, Mary put you in. Let me just open another Diet Coke, and we'll get started.

So you've had headaches for the past 20 years? And never seen a doctor before for them? What made you come in today, of all days, for this? Oh, you did a Google search.

Thank you for this printout of all the horrible types of brain tumors and aneurysms that can cause headaches and kill people. I appreciate it, because as a board certified neurologist with over 10 years of experience I really have no idea what sorts of things can cause headaches.

If you'd read it you might have noticed that the average survival from these awful things is 1-2 years, not 20. But I'm sure you're busy and didn't have time to actually read the articles you were printing up. After all, you had your hands full calling every neurologist on your insurance plan trying to find one who still had openings on this lovely Friday afternoon.

Of course we can get an MRI. I understand it would make you feel better, and allows me to cover my own legal butt, too.

Oh, you're claustrophobic? No, an MRI is really the best test we have right now for evaluating this sort of thing. I'm sorry that Reader's Digest somehow gave you the impression that I had a gadget in my office I could wave over you to make sure everything is okay, but I don't. Dr. McCoy borrowed my tricorder a while back and hasn't returned it yet. But we can do the MRI with Valium to relax you, if such a thing is possible.

I'll have my staff schedule the test for next week. No, I'm sorry. It's now 4:00 on a lovely Friday afternoon. Your insurance company requires an MRI request to be approved by a panel of dart-throwing chimpanzees before agreeing to pay for one. All of their offices are in another time zone, and have closed by now on this lovely Friday afternoon.

You really feel you need it immediately? Then the only thing I could suggest would be to go to an ER, and tell them you need an MRI right now. I'm sure, that after hearing your story and realizing how urgent this is, as opposed to a guy with chest pain, the ER doc will be happy to waste spend time and money on your case. Just don't tell him that I'm your doctor.

Oh, I had no idea your ER co-pay was so high. $50 does seem a bit extravagant for a lady with diamond rings on every finger and Porsche keys hanging out of your LV purse. I certainly can understand your refusal to go there.

Then it will have to be next week. My staff will call your insurance first thing Monday morning to get this authorized and scheduled.

Your insurance coverage runs out at the end of this month? My calender shows that today, May 29, is a Friday (which is a lovely afternoon by the way) and the last workday of the month. So Monday will be June, and we won't be able to get the MRI from your current insurance then, since it will have run out.

What insurance will you have on Monday? I'm sorry, I'm not contracted with that plan. I can send your internist a letter asking him to order the MRI. Oh, he's not contracted with it either. I see.

Yes ma'am, I agree it was entirely unreasonable of Mary to not have foreseen that you'd be changing to an insurance I don't take next week. You didn't mention that to her when you called for this appointment a few hours ago, but she really should have known, anyway. I'll discuss her suboptimal psychic powers with her at her next job evaluation in 2018.

I'm sorry you have to go already. Well, try to take it easy over the weekend, and I'll send my records to a neurologist on your next insurance, so they can help you out.

Going to a hockey game tonight sounds like fun, and it's great that you have such good seats. That looks like a nice air horn in your purse. I'm sure that sort of quiet, relaxed environment will help improve your headaches in the meantime. Thank you for sharing this lovely Friday afternoon with me.

I got dragged in to ER last night to see an acute stroke. In the next room there was a 16 year old guy wailing and screaming uncontrollably.

He'd taken the family car without permission. Wrecked it. Knocked over a traffic light, broken both legs. And (of course) didn't have a license.

He was fine and quiet with all this until he found out his mom was coming to the hospital. And then he REALLY freaked out. Not over the wreck... but because she'd see that he'd gotten a tattoo on his chest.

"Oh my God! She's going to kill me! She hates tattoos! Please! Somebody, give me a gown, a shirt, a towel, anything, please, I gotta cover this! Please! Why did you guys have to cut my shirt off? This is going to get me in such deep shit. Somebody! A blanket! Or even a big band-aid! Or something, anything, to put over it."

My 2:00 new patient yesterday didn't show up. It happens. I forgot about it and moved on.

Last night I got the following message on my voicemail:

"Dr. Grumpy, I'm never coming to see you again, and am going to complain about you to my internist. I had a 2:00 appointment with you today, and I waited in your lobby for 2 hours, and nobody called me back. I kept pointing this out to the girl at the front desk, and what did she do? NOTHING! She kept telling me that I didn't have an appointment there, and that I had the wrong office, and that you were in a different building! If this is how you treat new patients, then I don't see how you're still in practice."

Saturday, June 4, 2011

I don't watch doctor shows. I just don't care. But my Mom has always been a sucker for them.

"Pimping" is a longstanding tradition on teaching rounds. An attending physician routinely grills residents and medical students, partially to make them squirm and partially to teach them. The questions can be about medicines, diseases, conditions, or totally random ("the song that's playing in the elevator, what year is it from, and who was the group's lead singer?" I'M NOT MAKING THAT UP!).

In the mid-90's I'd graduated from medical school and was in residency training to become a neurologist. In the time-honored tradition of wayward children, I'd gone to my parents' house to do laundry. I was folding it in the family room, while mom watched a medical show.

On TV a bunch of white-coated figures were on rounds. Suddenly a senior physician looked at a medical student and asked "He's an alcoholic. Why do we give him thiamine, and not just glucose?"

Without thinking, I answered the question aloud (you get conditioned to do that). A few seconds later, a guy on TV said the exact same thing I just had.

And my mother, in wide-eyed astonishment, looked at me and said "Hey! How did you know that?"

Friday, June 3, 2011

Since I believe in fairness, I'd like to publish a response to my post about research in the lay press. A professional journalist was kind enough to mail me his take on the subject:

Dear Dr. Grumpy

To defend my profession:

You scientists DO understate the results of studies to "may possibly". It's not until you see lots of people die of something called "cancer" that you state the disease "isn't even a single disease- it's hundreds."

And a good scientist needs to have his or her nails removed without painkillers before one will state that, "XYZ causes ABC." How long did it take to figure out smoking causes cancer? That too much fat is not good for the heart?

That leaves Marty Anyreader wondering what the heck cancer is, and why, after throwing all that money at the problem, medical folks can't cure Cousin Tillie's breast cancer.

And you expect us journalists to explain that? We, who were the champion spitballers in the back of the room while you guys were soaking up all the teacher's attention? The ones who didn't take a single science course or even (gasp) statistics and probability in college?

Now, multiply that problem throughout the population of newspaper readers and television viewers. You have less than 30 seconds to explain a complicated scientific discovery to Marty Anyreader before he loses interest. So, editors think they have to "punch up" the story. Heaven forbid that he/she/it misses the Cure For Cancer!

Remember, as a journalist, our understanding of the basic science involved is sketchy at best. Readers/viewers is less than that (I know there are PhDs and the like out there, but ...)Anyway, I think you see the problem. It's like explaining to Ms. Anypatient that she has Glioblastoma Multiforme. You have more time than we do. A little more at least. And your patient has more interest

My suggestion (besides requiring basic science for journalism students) is that scientists keep writing for other scientists. The research is valuable even if it does wind up in "Genetics Research and Lab Decor." However, when the article is published know that there will be a writer from "Dead Rat Weekly" who is having "Pulitzerchosis" and is itching to be the next Woodward or Bernstein.

In defense of my hungry colleague: Dr. Hodgkin's results, no matter how obscure, still suggest SOMETHING that might stop the cancer's spread.

To a scientist that is promising. Worth looking at further. I don't know if the result in the math sense is a significant number, but to a layperson, it is interesting. To someone with ovarian cancer or a loved one with ovarian cancer, it's a lifeline.

Maybe (or maybe not) it's something that will treat human ovarian cancer. But at least it will add to our store of knowledge.

But remember what I said about the science background of most journalists. To Reporter Hungry and Editor Avarice, this is big stuff. So it gets headlines.

And then doctors get women and their families wanting to know why YOU aren't using Dr. Hodgkin's' latest advance.

*sigh*

There is your audience and your "translator" to the masses. Good luck.

Dr. Grumpy responds:

Thank you for your letter. I appreciate you sharing your side of the issue.

I agree with you. All research, and every breakthrough, has to start somewhere. People focus on Penicillin being discovered by accident, but ignore that those situations are exceedingly rare. The majority of medical breakthroughs take a lot of time, patience, and money.

The trouble isn't in the research, it's how people make a huge leap of illogic from preliminary findings in non-humans, and suddenly want that treatment TODAY! A lot of treatments that looked remarkably good in preliminary stuff (look up Dimebon if you wish) have later fizzled in large scale human trials.

One topic that I did NOT touch on is the number of times you guys are screwed over by an unscrupulous Dr. Hodgkin. It wasn't really the main theme of the post, but I could have written this instead:

"Let's say Dr. Hodgkin does some research on rat ovarian cells. He finds that in 25% of rats with ovarian cancer, there is a gene that may be able to stop cancer spread.

He gets published in the obscure journal Genetics Research and Lab Decor. But no one pays attention. And to continue his research, he needs money. And he'd also like a promotion. But his stuff is obscure enough that he doesn't get a grant.

So he calls Mr. Hungry Reporter, and "leaks" his results in a way that makes them sound far more promising, and immediate. Mr. Reporter isn't a scientist, and has to take the story at face value. So he publishes what Dr. Hodgkin told him, making it sound like the cure of ovarian cancer is close.

Now the attention is on Dr. Hodgkin. His university is in the spotlight, and suddenly wants to put money into his program (after all, they don't want to look like they're ignoring a cure for cancer), so they solicit donors and promote Dr. Hodgkin. When his research is, in fact, anything but groundbreaking. He's simply manipulated the media in a way that is unethical (or pretty damn close)."

I have NO idea how another blog, a non-English one, got linked to my feed. I haven't touched the settings since I set up the feed 6 months ago. I'm looking into it now. All the settings appear to be correct, and the feed source codes haven't been changed. So I'm hoping this is some odd technical glitch.

In case you live under a rock and missed it, the World Health Organization recently announced that cell phones "may possibly" cause cancer.

Now, I'm neither a researcher or statistician, and personally think the jury is still out on this one. I'm not going to take sides.

But here is what I am pissed off about: Notice that the story said "may possibly" cause cancer. But the way we think, it somehow becomes "does cause cancer", and so we panic, and hold our cell phones a yard from our head, and scream into them (that's gonna make driving while talking into one a helluva a lot safer, huh?).

"I can't hear you, Dave, but at least I may possibly not get cancer."

In my opinion a lot of the way this stuff gets played up as the top story on news outlets is just bullshit. It's no different than if I put "SEXXX" in screaming letters at the top of this post. It sure as hell would get your attention, and snag a few search engines, but the post has little, if anything, to do with sex (unless you're into setting the phone on vibrate and...)

This is the nightmare of medical research in the lay press. Let's say Dr. Hodgkin does some research on rat ovarian cells. He finds that in 25% of rats with ovarian cancer, there is a gene that may be able to stop cancer spread.

So he gets published in the journal Genetics Research and Lab Decor. A hungry reporter finds the article, and sees a great way to sell papers with a story on how ovarian cancer has been cured!

Now this isn't what Dr. Hodgkin said. His research had a 25% success rate in curing mice with a certain type of ovarian cancer. The most he might say is that someday this might lead to new methods of treating some types human ovarian cancer.

But, of course, nobody gives a shit about mice with cancer. A headline saying "25% Of Mice with Ovarian Cancer May Someday be Cured!" wouldn't get anyone's attention. But if you make a huge leap of illogic, extrapolate it to humans, and put up "CURE FOR OVARIAN CANCER NEAR!", it will sell newspapers and draw readers, no matter how far off from the truth it is.

For those of you who remember, in the mid-80's there was a HUGE media circus about how Interleukin-2 was THE cure for cancer (an absurdity, if you think about it, considering that cancer isn't even a single disease- it's hundreds). Major news magazines and TV networks ran stories about it. It made the front page... and that was about it. Not to take anything away from Interleukin-2. It eventually did settle down and find a place in malignancy treatment. But was it the miracle breakthrough that it got played up as? Not even close.

By the same token, in the 1970's EVERYONE knew Saccharin caused cancer. So it got a big black box on every product that contained it. And after several years it was quietly found that it DIDN'T. Of course, when the second story came out it was relegated to the back page, and people didn't notice when the warning labels disappeared. Because it's more interesting to scare people, or give them false hope, than to reassure them.

Certainly there are plenty of things that are clearly proven to cause cancer: cigarettes, for example. But hell, at this point we all know that. So it's not going to get attention. But put up a headline about something we believe is harmless (unless you're trying to pass a cell phone talker on the freeway) and it will get a lot of readers.

So let's get back to the cell phones.

What really grates my crank is the use of "may possibly" or "possibly" or "may be linked to..." that the articles about this are so full of. NOT "does" or "doesn't" but simply different variations on ambiguity which, while getting your attention, DON'T REALLY SAY A FUCKING THING!!!

Look at it this way. "Cell phone use may possibly cause cancer". How is that different from "cell phone use may or may not cause cancer"? But if the second sentence was used, you'd say "No shit, Sherlock" and skip the article.

To take it a step further, let's use the "may possibly" phrase in other circumstances, and see how definitive that sounds:

"Mrs. Smith, you may possibly be pregnant."

"Dave, you may possibly be fired."

"You're going to see Dr. Grumpy? I heard he may possibly be competent."

"The Grumpyville Faceplants may possibly win the Super Bowl."

"Congrats, Cindy. You may possibly be getting a promotion."

"Dude! There may possibly be beer and girls at the party!"

"OMG Buffy! Your new boyfriend may possibly be HAWT!"

"KIDS! You may possibly be punished if you don't clean up your damn rooms!"

Doesn't give you a lot of confidence, or clarity, does it?

So next time you see a medical research news story, think about how accurate it may possibly be.

Mrs. Powder: "You'd think he'd get over being such a baby about it. I made him wait in the car until I'd finished the laundry. Anyway, at the last visit you had me try Maxalt, and I like it. Do you have any more samples?"

Welcome to my whining!

This blog is entirely for entertainment purposes. All posts about patients may be fictional, or be my experience, or were submitted by a reader, or any combination of the above. Factual statements may or may not be accurate.

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Dr. Grumpy is for hire! Need an article written (humorous, medical, or otherwise) or want to commission a genuine Grumpy piece for your newspaper/magazine/toilet paper roll? Contact me to discuss subjects. You can reach me at the email address below.

Note: I do not answer medical questions. If you are having a medical issue, see your own doctor. For all you know I'm really a Mongolian yak herder and have no medical training at all except in issues regarding the care and feeding of Mongolian yaks.